Interest and appreciation for palliative care (PC) has resulted in increased demand for both PC services and education. The PC rotation has been shown to improve PC knowledge in medical students (MS) and internal medicine (IM) residents, and PC specialists stand poised to direct the primary PC education of learners at different levels of training. To concurrently teach learners of different levels of training on a busy PC service, we created an educational system that emphasizes management of learner schedules, organization of teaching activities, faculty development to improve teaching skills, and learner self-evaluation. Both MS and IM residents showed an improvement in self-assessed competence as well as increased comfort level with seriously ill patients after PC rotation. Careful adjustment of learner schedules has accommodated an increasing number of learners, while maintaining a low learner to faculty ratio. The PC educators face an exciting and daunting challenge as the number of patients with PC needs and the number of learners requesting PC experience grow. We continue to improve milestone-based PC assessment tools, to invest in faculty development, and to explore innovative ways to support PC educators as they strive to provide consistent PC education that is both useful for learners and can be incorporated into busy PC clinical practice.

BACKGROUND: With the rapid growth in the number of fellowship programs in Hospice and Palliative Medicine (HPM), many are in the process of developing ways to demonstrate that fellows are attaining educational milestones. Reflection and self-assessment are key components of 2 Accreditation Council for Graduate Medical Education (ACGME) competencies, practice-based learning and improvement, and systems-based practice, which have both been historically challenging to learn and assess.
OBJECTIVE: This article describes results of a content analysis of narrative data collected from HPM fellows' self-assessments as they performed hospice home visits independently in a new clinical rotation.
DESIGN: This was a prospective qualitative study.
SETTINGS/PARTICIPANTS: Eight fellows completed 217 unsupervised hospice home visits from 2014 to 2016.
MEASUREMENTS: Fellows completed weekly self-assessment forms, which captured both clinical visit information and practice data elicited from responses to open-ended reflection prompts.
RESULTS: Analysis of 29 self-assessment forms generated 6 themes: patient- and family-centered care, self-efficacy, systems-based care, commitment to doing their best, catalyst for professional growth, and purpose and meaning in work. The fellows recognized numerous barriers distinct to providing care in homes. All fellows felt prepared to perform home visits throughout the rotation and after training.
CONCLUSIONS: Narrative data collected during the independent home visit rotation provided evidence that HPM fellows detected gaps in their performance, planned for practice improvements in subsequent visits, and valued working within an interprofessional team. Built-in opportunities for fellows to reflect during training are critical in meeting ACGME milestones, and are integral to their professional development.

BACKGROUND: Virtual reality (VR) immersive environments have been shown to be effective in medical teaching. Our university hospital received funding from our deanery, Health Education in Wales, to film teaching videos with a 360-degree camera.
AIMS: To evaluate whether VR is an effective and acceptable teaching environment. VR headsets were set up for medical students who rotated through Velindre Cancer Hospital's Palliative Care department.
METHODS: Students were asked to put on a VR headset and experience a pre-recorded 27 min presentation on nausea and vomiting in palliative care settings. They subsequently viewed a radiotherapy treatment experience from a patient's point of view.
RESULTS: Of the 72 medical students who participated, 70 found the experience comfortable, with two students stating they felt the experience uncomfortable (1=too tight; 1=blurry visuals). Numerical scoring on ability to concentrate in VR from 0 to 10 (0=worst, 10=best) scored an average of 8.44 (range, 7-10). Asked whether this format suited their learning style, average score was 8.31 (range 6-10). 97.2 % (n=70) students stated that they would recommend this form of learning to a colleague, with one student saying he/she would not recommend and another stating he/she was unsure. Students left anonymous free-text feedback comments which helped frame future needs in this emerging area.
DISCUSSION: This study suggests that there is room for exploring new ways of delivering teaching and expanding it more widely in palliative care and oncology, but also provides feedback on areas that need further careful attention. Comments from students included: "Might have been the novelty factor but I learnt more from this 20 min VR thing than I have from many lectures".
SUMMARY: The project has proved sufficiently popular in medical student feedback, that the VR experience is now available on YouTube and has been permanently introduced into routine teaching. Further 360-degree teaching environments have been filmed. Of note is that our 360-degree videos have been viewed in Africa, so this format of teaching could prove valuable due to its global reach.

Context: Although palliative care is rapidly being disseminated throughout Japan as a result of government policy, a systematic syllabus of palliative medicine for physicians has not been developed.
Aims: This study aimed to develop a Japanese national consensus syllabus of palliative medicine for physicians.
Design: We used a modified Delphi method to develop the consensus syllabus.
Methods and Setting: We created a Delphi panel by selecting 20 expert eligible panelists consisting of Diplomate or Faculty of the Specialty Board of Palliative Medicine and certified by the Japanese Society for Palliative Medicine. We inducted external reviewers from 11 palliative care-related organizations.
Results: Among 20 experts surveyed, 20 (100%) responded over all rounds. Ten (50%) participated in a panel meeting. In the first round, 179 of 179 (100%) learning objectives were judged to be appropriate and 5 of 179 (3%) learning objectives were judged to be too difficult. In the panel meeting, 25 learning objectives were excluded, three new learning objectives were added, and 15 learning objectives were reworded. In the second round, 18 of 18 (100%) learning objectives were judged to be appropriate. The final version of the syllabus developed consists of 157 specific behavioural objectives and 22 general instructional objectives across 22 courses.
Conclusions: We have developed the first national consensus syllabus of palliative medicine for physicians in Japan. Based on this syllabus, a training program on palliative medicine will be established by training facilities in Japan, and physicians will be able to practice specific palliative care.

As the number of older adults and those with chronic medical conditions continues to rise, the need to train social work students in palliative and end-of-life competencies becomes critical. To address this growing need, the social work team at a large urban academic medical center in the Midwest developed an MSW concentration practicum in palliative and end-of-life care. During the practicum, students receive immersive training in palliative care social work values and the skills required for these specialized assessments, interventions, and evaluations. Their training culminates in their participation on an interdisciplinary team to provide psychosocial support to patients and families receiving palliative and end-of-life care throughout the medical center. This article describes the curriculum, practice immersion, training manual, teaching modules, and structure of student supervision which is applicable to and adaptable for other palliative care social work field instructors.

BACKGROUND: Effective leadership is necessary to meet the complex care needs of patients with serious, life-limiting illness. The Cambia Health Foundation Sojourns Scholars Program is advancing leadership in palliative care through supporting emerging leaders. The 2016 Cohort has implemented a range of projects to promote their leadership development.
OBJECTIVE: To describe the leadership themes emerging from individual project implementation of the 2016 Sojourns Leadership.
METHODS: We summarize the synthesized leadership themes derived from both remote and in-person meetings and written reflections of the 2016 Cambia Sojourn Leadership Cohort.
RESULTS: The 2016 Cambia Sojourn Leadership Scholar Cohort projects are described. We identified three leadership themes related to palliative care initiatives: openness and flexibility, partnership and team building, and leveraging expertise and risk.
DISCUSSION: Unprecedented challenges in a rapidly changing health environment demand palliative care leadership to influence care quality, delivery, policy, and clinical care. Flexibility and openness; partnership and team building; and expertise to implement change emerged as critical themes to advancing the care of patients with serious, life-limiting illness. These leadership themes are consistent with both previous Cambia Sojourns Scholar cohorts and the literature, are essential for the next generation of leaders to implement new models of quality palliative care, payment for palliative care, and education for patients, caregivers, and health care providers.
CONCLUSION: In order to design and implement quality palliative care, leadership development is essential. Use of flexibility and openness; partnership and team building; and expertise to implement change are important themes for success. Whether through the Cambia Health Foundation Sojourns Leadership Program or opportunities within professional organizations, cultivation of the next generation of leaders is critical.

Introduction: Care of the dying older adult includes critical skills that emerging physicians should master but are not consistently taught. Simulation has been shown to be an excellent tool for teaching these skills in a standardized fashion. Simulation allows direct observation to assess and provide learner feedback. Our goal was to develop a learning activity to practice skills caring for the older adult at the end of life and identify areas in need of improvement.
Methods: We developed a hybrid simulation in which fourth-year medical students and internal medicine (IM) residents cared for a 70-year-old patient (Laerdal SimMan 3G) who was actively dying in the emergency department. He was accompanied by his wife (standardized patient) and a nurse (standardized role). Over the academic year 2012-2013, we observed and videotaped 83 fourth-year medical students and 22 first-year IM residents in this setting. We assessed the learners' completion of 15 tasks associated with good end-of-life care.
Results: All learners demonstrated professional activity working with the nurse, and all medical students but one gave opioids appropriately for pain. Only 19% of the medical students appropriately disclosed the patient's status to the wife using the words death and/or dying, and only 50% of the IM residents did so.
Discussion: We successfully developed a learning activity in which learners can practice their skills caring for the dying older adult. We also determined that there is opportunity for improvement concerning communication, especially with the use of the words death and dying.

Palliative and supportive care education for radiation oncologists in training is essential to deliver comprehensive care to patients. Surveys on palliative care education among radiation oncology program directors and residents demonstrate a disparity in formal teaching and didactics. Integration of formal didactics, communications skills programs, and teaching modules are being piloted at academic centers. A dedicated palliative radiation oncology service has been implemented and the experience evaluated. Future directions to improve resident education in palliative care include improving access and time dedicated to formal didactics, online and interactive modules, rotation in a palliative care service, emphasis on board examinations, and consideration of an advanced palliative care fellowship for radiation oncologists. This is the first review of the available literature reviewing formal palliative education in radiation oncology training programs in the United States.

INTRODUCTION: Medical trainees and professionals do not perceive that they are adequately taught the skills to address issues of grief with their patients. Atypical grief responses can prolong suffering, interrupt normal activities and lead to increased morbidity and mortality. Grief training can help physicians cope with feelings about and responses to suffering, loss and death in a way that improves both physician and patient/family wellness. This scoping review will describe the current landscape of grief training worldwide in medical school and residency and in continuing professional development in the disciplines of paediatrics, family medicine and psychiatry. The ultimate goal is to help physicians support patients experiencing grief.
METHODS AND ANALYSIS: The study design has been adapted from Arksey and O'Malley's review methodology. We will work with an information specialist who will run searches in six multidisciplinary databases. To supplement the search, we will scan the reference lists of included studies. Two levels of screening will take place: a title and abstract review for articles that fit predefined criteria and a full-text review of articles that meet those criteria. To be included in the review, articles must report on grief training for medical residents and professionals in the fields of paediatrics, family medicine and psychiatry. Two investigators will review each article and extract data.
ETHICS AND DISSEMINATION: Research ethics approval is not required for this review. We plan to share the findings through national and international medical education conferences and to publish the results in a peer-reviewed academic journal. We have the support of several directors of medical education at our institution who are interested in the growing focus on humanism in medical education as a way of decreasing burnout among medical students, residents and faculty.

OBJECTIVE: Palliative social workers have taken steps to increase the numbers of social workers trained and competent to deliver effective psychosocial palliative care. Despite these developments, masters of social work (MSW) programs have only begun to develop curricula preparing students for entry-level practice. This study sought to determine the type and extent of content areas included in MSW courses dedicated to palliative care or with content related to palliative care practice.
METHOD: A cross-sectional study using an online questionnaire was conducted. All 248 accredited MSW programs in the United States and 32 programs in Canada were invited to participate. Participants were asked to name the courses in their MSW program that were dedicated to, or included content on, palliative care, and submit the syllabi for these courses. Data comprised course content for each class session and required readings. A grounded theory approach was used to identify the topics covered. Result: Of the 105 participating programs that responded to the survey, 42 submitted 70 syllabi for courses with at least some palliative care content. There were 29 topics identified. The most common topic was grief, loss, and bereavement, followed closely by behavioral and mental health issues, and supporting family and friends; cultural perspectives and advance care planning were also common topics. For the 10 syllabi from courses dedicated to palliative care, supporting family was the most common topical area, followed closely by interprofessional practice and advance care planning.Significance of results: Although there are many challenges to introducing palliative care content into MSW programs, including unqualified faculty and competing course material and electives of equally compelling content, there are model curricula for dedicated palliative care courses. With the large growth of palliative care programs, the time is ripe to add specialty palliative care courses and to add palliative care content into existing courses.

BACKGROUND: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together. There is an imperative to teach young physicians early in their training the importance of engaging in a shared decision-making process to define overall goals of care (GOC). The PERSON mnemonic proposes a structured format that allows providers to evaluate GOC across the spectrum of serious illnesses, outside of breaking bad news or end-of-life planning.
OBJECTIVES: This study evaluated the utility of the PERSON mnemonic in training residents to have GOC with their patients, and investigated if these skills translated to the bedside with real patient encounters.
METHODS: First-year residents were divided into groups to participate in an in-depth education session. A pre-/postbaseline survey was administered immediately after the education intervention and approximately seven months later to assess retention and utility.
RESULTS: Thirty first-year residents were eligible for this study; 30 attended the educational sessions and completed the immediate baseline pre-/postsurvey and the seven-month follow-up survey, resulting in 100% retention rate throughout study. Residents found sustained utility in the mnemonic. It was significantly successful in increasing the knowledge and confidence level in exploring GOC. Patient-centered outcomes could not be analyzed due to low response rates and limited granularity of hospital-level data.
CONCLUSION: The PERSON mnemonic is a feasible and useful format for teaching residents how to have a GOC discussion.

What is known about the topic?
Palliative medicine is increasingly encountered in an emergency medicine setting, and emergency medicine residents desire further training in this field.
What did this study ask?
How many postgraduate emergency medicine programs in Canada have an existing palliative medicine curriculum?
What did this study find?
A minority (38.5%) of emergency medicine programs report having a formal palliative medicine curriculum, and the contents are variable.
Why does this study matter to clinicians?
It will be important to define how trainees will achieve competence in palliative medicine in the emergency department.

Objectives: Physicians working with palliative patients have a substantial risk of emotional exhaustion because of their daily confrontation with suffering and death. Common concerns include alexithymia, high stress, low perceived social support and a greater burnout risk. This longitudinal study aimed to evaluate the effectiveness of Balint training in preventing the development of these symptoms in these medical professionals. Material and Methods: The design of the study was longitudinal. A group of 69 physicians working with palliative patients from 5 county hospitals in Romania (33 men, 36 women) participated in the study. Out of them, 31 joined and systematically attended a local Balint group whereas the others did not participate in such a group, either during the study or previously. They were given, both at the beginning (2015) and at the end of the study (2017), 4 psychometric instruments assessing alexithymia (Bagby’s Toronto Alexithymia Scale), perceived stress (Cohen and Williamson’s Perceived Stress Scale), social support (Duke-UNC Functional Social Support Questionnaire) and burnout (Maslach Burnout Inventory). A split-plot ANOVA analysis was used for evaluating the significance of Balint groups participation, with gender and age considered as auxiliary variables.
Results: In the study group, Balint training significantly improved the scores of global burnout (F(1, 64) = 25.104, p < 0.0001), 2 of its components (emotional exhaustion (F(1, 64) = 18.390, p < 0.0001) and depersonalization (F(1, 64) = 10.957, p < 0.002), alexithymia (F(1, 64) = 3.461, p < 0.0001) and perceived social support (F(1, 64) = 57.883, p < 0.0001), but not the scores of perceived stress and low personal accomplishment. Gender had an additional contribution in decreasing alexithymia (F(1, 64) = 7.436, p < 0.009) and increasing perceived social support (F(1, 64) = 15.426, p < 0.0001), with higher effects in men. Conclusions: This study points to the potential usefulness of Balint training in addressing alexithymia and burnout, and in improving perceived social support among physicians working with palliative patients. As the Balint method is easily understood and does not require special investments, it could represent a cost-effective instrument of addressing job-related psychological risks.

Background: Nursing students have limited opportunities to experience end-of-life care, so it is difficult for them to learn how to deliver it empirically. The use of simulations with standardized patients may be a way to provide realistic experience of end-of-life care for nursing students.
Objectives: The aim of this study was to evaluate the effectiveness of end-of-life care simulations with standardized patients in improving the knowledge, skill performance and self-confidence of undergraduate nursing students.
Design: Randomized controlled study.
Setting: Japanese university nursing school.
Participants: Thirty-eight students in the third year of the Bachelor's degree in nursing (simulation group = 20, control group = 18).
Methods: After randomization to a simulation or control group, participants in the simulation group participated in an end-of-life care simulation with standardized patients. The primary outcome of a change in the knowledge score was assessed using a knowledge questionnaire, skill performance by completing Objective Structured Clinical Evaluations, and self-confidence related to end-of-life care by self-reported questionnaires.
Results: The simulation group improved significantly in knowledge, skill performance in physical assessment and psychological care, and self-confidence related to end-of-life care. The results of the two-way analysis of variance showed a significant interaction between groups and time (p = 0.000). Analysis of the simple main effect showed a significant difference (p = 0.000) between groups after the end-of-life care simulation and a significant difference (p = 0.000) over time in the simulation group. There were large effects on knowledge improvement ( 2 = 0.372), physical assessment ( 2 = 0.619), psychological care skill performance ( 2 = 0.588), and self-confidence in both physical assessment ( 2 = 0.410) and psychological care ( 2 = 0.722).
Conclusions: End-of-life care simulation with standardized patients would be an effective strategy to train nursing students, who have limited opportunities to experience end-of-life

Arguably, deciding the timing and manner of one's death is the biggest decision of all. With the Victorian Voluntary Assisted Dying Act commencing in 2019, assessing capacity to choose Voluntary Assisted Dying (VAD) becomes a critical issue for clinicians in Victoria, and elsewhere with ongoing efforts to change the law across Australia and in New Zealand. We consider how capacity assessment and undue influence screening can be approached for VAD, the role and risks of supported decision-making, and argue for the importance of training to ensure health care professionals are educated about their role.

Palliative care is the holistic care of patients with advanced, progressive incurable illness. Palliative care is well recognized as an essential component of medical student curricula. However, teaching is variable within medical schools. Using current literature, these tips aim to highlight key points necessary to facilitate the development and delivery of palliative care teaching to medical students. The key practice points include: clinical exposure to patients with palliative care needs and those that are dying, being compulsory (and integrated) across the course, summative and formative assessments to encourage learning, support from within the university for curricular time and development, visits to a hospice/inpatient palliative care facility, emphasis on clinically based learning later in the course, teaching by specialists in palliative care as well as specialists in other areas including Family Doctors/General Practitioners, innovative teaching methods and inter-professional learning to develop teaching.

Introduction: There is increasing recognition that Surgical Palliative Care is an essential component of the holistic care of surgical patients and involves more than end-of-life care in the intensive care unit. General surgery residents are clinically exposed to patients with palliative care needs during each year of training, but few have a dedicated surgical palliative care curriculum. We undertook this educational needs assessment as the first step towards a longitudinal curriculum.
Methods: We conducted an anonymous survey of 94 general surgery residents and 115 faculty at community and university hospitals to assess their experience and comfort with surgical palliative care delivery. Residents and faculty were asked multiple choice and open-ended questions.
Results: There was a 55% response rate from residents and 33% response rate from faculty. The majority (77%) of respondents were junior residents (PGY1-3) and university-based faculty (66%). Approximately half of residents felt comfortable leading conversations in goals of care (58%), comfort-focused care (52%) and delivering bad news (57%), while greater than 90% of faculty agreed that chief residents needed additional training. All residents agreed they needed additional training and 85% wanted a formal curriculum. Analysis of open-ended questions suggests a deficiency in the pre-operative setting as no residents had participated in these conversations in an outpatient setting.
Conclusion: Residents and faculty believe trainees would benefit from further education in surgical palliative care with a dedicated curriculum. The outpatient, pre-operative counseling of patients was identified as a key learning need. These data support our ongoing work to develop a surgically pertinent palliative care curriculum.

CONTEXT: A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define Curricular Milestones (CM) for Hospice and Palliative Medicine (HPM) fellowship programs. The developed list of CMs would serve as components upon which to organize curriculum and standardize what to teach during training. These would complement Entrustable Professional Activities (EPA's) previously developed by this group and new specialty specific Reporting Milestones (RM's) for HPM developed through the ACGME.
OBJECTIVES: To develop and vet CMs for HPM fellowships in the United States.
METHODS: A draft of CMs was developed through an iterative consensus group process with repeated cycles of drafting, analyzing and revising by a broadly representative expert workgroup who then gained input from HPM educators at a national meeting workshop. The CM draft was subsequently revised and then vetted through a national survey to 203 fellowship educators. Respondents were asked to "keep", "revise", or "exclude" each proposed CM with space for comments. An agreement of 75% among respondents was set as the criteria a priori for keeping a CM. 84 of the 203 potential respondents participated in the survey. All items met the minimum agreement level of 75% or greater recommending keeping the CM. Greater than 85% of the respondents agreed to keep 19 of the 22 CMs with no revisions. Comments for revisions on other CMs were primarily related to changes in language and formatting, not conceptual underpinnings.
CONCLUSION: A group consensus method strengthened by inclusion of a national survey to HPM fellowship educators resulted in a CM document that is both carefully developed and broadly vetted. Along with EPA's and new specialty specific RM's, these CM's offer educators and trainees tools to create more comprehensive curricula and behaviorally based assessment tools for HPM fellowships and their stakeholders.

To assess perspectives of US community-based palliative care program leaders on staffing, recruitment, and training, a qualitative descriptive study was conducted. Leaders (n = 20) from academic medical centers, large integrated and community health systems, home health and hospice organizations, and the Veterans Administration were recruited. Three major categories emerged that influence community-based palliative care workforce team composition across settings: (1) staffing models and recruitment are influenced by setting and workforce experience, (2) training varies by setting, and (3) demand exceeds supply of trained workforce. Participants described a hybrid approach used in academic and community settings to complete an interdisciplinary team by leveraging social work and chaplaincy from inpatient departments and home health and hospice. Physician-led interdisciplinary teams in academic settings and teams more often led by nurse practitioners in community settings were reported. Community program leaders expressed the desire to recruit nurses with home health and hospice experience because of the ability to work independently. Training was described as more often on-the-job in community settings. Turnover related to the lack of a properly trained workforce was described as one of the biggest barriers to palliative care development.